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Urits I, Li N, Berger AA, Walker P, Wesp B, Zamarripa AM, An D, Cornett EM, Abd-Elsayed A, Kaye AD. Treatment and Management of Loin Pain Hematuria Syndrome. Curr Pain Headache Rep 2021; 25:6. [PMID: 33495883 DOI: 10.1007/s11916-020-00925-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.,Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Nathan Li
- Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Amnon A Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Paul Walker
- Weill Cornell Medical College, New York, NY, USA
| | - Brendan Wesp
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alec M Zamarripa
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Daniel An
- Georgetown University School of Medicine, Washington, DC, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
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Lugo-Gavidia LM, Nolde JM, Kiuchi MG, Shetty S, Azzam O, Carnagarin R, Schlaich MP. Interventional Approaches for Loin Pain Hematuria Syndrome and Kidney-Related Pain Syndromes. Curr Hypertens Rep 2020; 22:103. [PMID: 33128173 DOI: 10.1007/s11906-020-01110-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Loin pain hematuria syndrome (LPHS) frequently presents with severe chronic pain that poses a clinical challenge. Current treatment approaches are mostly empirical and include a wide range of therapeutic strategies such as physical therapy, local and systemic analgesia, interventional and surgical approaches usually flanked by psycho-behavioral therapy, and other strategies. LPHS often impacts negatively on quality of life particularly in patients who are refractory to treatment. RECENT FINDINGS With recent advances in catheter-based treatment approaches and better understanding of the pathophysiology of LPHS, intraluminal renal denervation (RDN) has been proposed as a valuable treatment option for kidney-related pain syndromes. The present review provides a brief overview of the clinical challenges associated with LPHS, highlights recent insights into its underlying mechanisms, and summarizes currently available data on the use of RDN in the context of LPHS and kidney-related pain syndromes. Renal denervation via various approaches including surgical and catheter-based techniques has shown promise in alleviating kidney-related pain syndromes. Randomized controlled trials are now required to better define its role in the management of these conditions.
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Affiliation(s)
- Leslie Marisol Lugo-Gavidia
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, Rear 50 Murray St, Perth, WA, 6000, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, Rear 50 Murray St, Perth, WA, 6000, Australia
| | - Márcio Galindo Kiuchi
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, Rear 50 Murray St, Perth, WA, 6000, Australia
| | - Sharad Shetty
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia
| | - Omar Azzam
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, Rear 50 Murray St, Perth, WA, 6000, Australia
- Departments of Internal Medicine, Royal Perth Hospital, Perth, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, Rear 50 Murray St, Perth, WA, 6000, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit, University of Western Australia, Level 3, MRF Building, Rear 50 Murray St, Perth, WA, 6000, Australia.
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia.
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.
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Taba Taba Vakili S, Alam T, Sollinger H. Loin Pain Hematuria Syndrome. Am J Kidney Dis 2014; 64:460-72. [DOI: 10.1053/j.ajkd.2014.01.439] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 01/17/2014] [Indexed: 11/11/2022]
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Bhandari A, Ellias M. Loin pain hematuria syndrome: Pain control with RFA to the splanchanic plexus. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856900750233811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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de Beus E, Blankestijn PJ, Fox JG, Zoccali C. Catheter-based renal denervation as a novel treatment for loin pain haematuria syndrome. Nephrol Dial Transplant 2013; 28:2197-9. [DOI: 10.1093/ndt/gft225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ahmed M, Acher P, Deane AM. Ureteric bupivicaine infusion for loin pain haematuria syndrome. Ann R Coll Surg Engl 2010; 92:139-41. [PMID: 20353642 DOI: 10.1308/003588410x12628812458338] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Loin pain haematuria syndrome is a common problem with complications including opiate dependence. Morbidity treatments include intra-ureteric capsaicin infusion, nephrectomy, autotransplantation and nephrolysis. We explored the use of flexible cystoscopic infusion of intra-ureteric bupivicaine. PATIENTS AND METHODS Patients presenting with chronic loin pain underwent urological and nephrological evaluation. Bupivicaine (0.5%, 20 ml) was infused via an intra-ureteric catheter under flexible cystoscopic guidance. Repeat infusions were offered if indicated. RESULTS Sixteen of 17 patients with 1-year follow-up responded and were satisfied. Twelve of these required repeat infusions (mean, 2.9 infusions). The procedures were well tolerated by all patients without adverse effects. CONCLUSIONS Intra-ureteric bupivicaine infusion has a place in the management of patients with chronic renal pain. It offers a minimally invasive alternative to other treatments. This procedure warrants further investigation within a randomised, controlled trial setting.
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Affiliation(s)
- M Ahmed
- Department of Urology, Kent and Canterbury Hospital, Canterbury, UK.
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Goroszeniuk T, Khan R, Kothari S. Lumbar Sympathetic Chain Neuromodulation with Implanted Electrodes for Long-Term Pain Relief in Loin Pain Haematuria Syndrome. Neuromodulation 2009; 12:284-91. [DOI: 10.1111/j.1525-1403.2009.00237.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Endoscopic findings in loin pain hematuria syndrome: concentric clot in calyceal fornices. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2009; 2008:721850. [PMID: 19229344 PMCID: PMC2643052 DOI: 10.1155/2008/721850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 12/25/2008] [Indexed: 11/17/2022]
Abstract
The loin pain hematuria syndrome (LPHS) creates a considerable burden, both for patients afflicted with the disease and for those involved in medical management and diagnosis. To date, the diagnosis of LPHS remains one of exclusion, with some speculation regarding the extent of actual pathology. We report ureteroscopic findings in 2 cases of LPHS. These findings provide objective confirmation of underlying pathology in a difficult-to-manage disease process.
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Affiliation(s)
- G K Dube
- Division of Nephrology, Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, New York 10032, USA
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Spetie DN, Nadasdy T, Nadasdy G, Agarwal G, Mauer M, Agarwal AK, Khabiri H, Nagaraja HN, Nahman NS, Hartman JA, Hebert LA. Proposed pathogenesis of idiopathic loin pain-hematuria syndrome. Am J Kidney Dis 2006; 47:419-27. [PMID: 16490620 DOI: 10.1053/j.ajkd.2005.11.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 11/28/2005] [Indexed: 11/11/2022]
Abstract
BACKGROUND To study loin pain-hematuria syndrome (LPHS) pathogenesis, we evaluated 43 consecutive patients for whom urological evaluation failed to disclose the cause of their recurrent flank pain and hematuria. Each underwent percutaneous kidney biopsy. In 9 patients, the biopsy specimen showed immunoglobulin A nephritis, an established cause of LPHS. We suggest these cases be designated secondary LPHS. They are not included in this analysis. The remaining patients (N = 34) are designated idiopathic (primary) LPHS. They are the basis of this report. METHODS Demographics of patients with primary LPHS are mean age of 30.8 +/- 10.3 years; 74% women; 94% white; and history of kidney stones, 47%, although none was obstructing. RESULTS Primary LPHS kidney biopsy specimens showed red blood cells (RBCs) in multiple tubules, consistent with glomerular hematuria. Glomeruli were normal by means of light and immunofluorescent microscopy; however, more than 50% of biopsy specimens showed unusually thin or thick glomerular basement membranes. To assess whether the biopsy itself caused RBCs in tubules, we compared RBCs in renal tubular cross-sections from primary LPHS biopsies with those of normal kidneys (donors, n = 10). The mean percentage of tubular cross-sections containing RBCs was greater in primary LPHS than normal specimens (7.2% +/- 6.5% versus 1.6% +/- 1.0% [SD]; P < 0.0001), confirming glomerular hematuria in patients with primary LPHS. CONCLUSION Primary LPHS pathogenesis includes glomerular hematuria, apparently from structurally abnormal glomerular basement membrane. Primary LPHS pain may be initiated by obstructing RBC casts and perhaps microcrystals in those with a history of urolithiasis. Nevertheless, other factors are needed to explain the severe pain in patients with primary LPHS.
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Affiliation(s)
- Dan N Spetie
- Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
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Tentori F, Stidley CA, Scavini M, Shah VO, Narva AS, Paine S, Bobelu A, Welty TK, Maccluer JW, Zager PG. Prevalence of hematuria among Zuni Indians with and without diabetes: The Zuni kidney Project. Am J Kidney Dis 2003; 41:1195-204. [PMID: 12776271 DOI: 10.1016/s0272-6386(03)00351-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is an epidemic of kidney disease among the Zuni Indians. In contrast to other American Indian tribes, the epidemic among the Zuni Indians is attributable to diabetic and nondiabetic renal disease. METHODS The Zuni Kidney Project, established to reduce the burden of renal disease, conducted a population-based cross-sectional survey of Zuni Indians aged 5 years or older to precisely estimate the prevalence of hematuria. The survey used neighborhood household clusters as the sampling frame to maximize ascertainment and minimize bias. During the survey, we administered a questionnaire; collected blood and urine samples; and measured blood pressure, height, and weight. RESULTS Age and sex distributions in our sample (n = 1,469) were similar to those of the eligible Zuni population (n = 9,228). Prevalences of hematuria, defined as dipstick of trace or greater and 50 red blood cells/microL or greater, age- and sex-adjusted to the Zuni population aged 5 years or older, were 33.2% (95% confidence interval [CI], 30.7 to 35.6) and 17.8% (95% CI, 15.8 to 19.8), respectively. Hematuria of trace or greater was more common among females (40.6%; 95% CI, 37.0 to 44.1) than males (25.1%; 95% CI, 21.8 to 28.4). Hematuria of trace or greater was common among Zuni Indians without diabetes (females, 39.7%; 95% CI, 35.7 to 43.8; males, 22.7%; 95% CI, 19.4 to 26.1) and with diabetes (females, 47.5%; 95% CI, 39.8 to 55.2; males, 45.8%; 95% CI, 34.3 to 57.3). Diabetes and alcohol use for greater than 10 years were associated with hematuria among males, but not females. CONCLUSION The prevalence of hematuria is high among Zuni Indians with and without diabetes. These findings are consistent with the hypothesis that nondiabetic kidney disease is common among Zuni Indians with and without diabetes.
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Affiliation(s)
- Francesca Tentori
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87131-5241, USA
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Armstrong T, McLean AD, Hayes M, Morgans BT, Tulloch DN. Early experience of intra-ureteric capsaicin infusion in loin pain haematuria syndrome. BJU Int 2000; 85:233-7. [PMID: 10671874 DOI: 10.1046/j.1464-410x.2000.00469.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate early results of the intra-ureteric instillation of capsaicin for the treatment of loin pain haematuria syndrome (LPHS). PATIENTS AND METHODS Ten patients with LPHS were treated using intra-ureteric capsaicin instillation. A solution of capsaicin was infused into the affected ureter through an embolectomy catheter, under anaesthesia. The success of the treatment was assessed using patient questionnaires and the quantitative reduction in the patients' analgesic requirements measured. RESULTS During a mean follow-up of 6 months, six of the 10 patients had short- to medium-term symptomatic relief after one or more treatments; four had no relief from their symptoms. One patient had a mucosal ulceration in the bladder after extravasation of the capsaicin solution. Two patients subsequently underwent simple nephrectomy for symptomatic nonfunctioning kidneys. CONCLUSION These results are consistent with other preliminary reports of the efficacy of capsaicin treatment in LPHS and such treatment therefore has a definite therapeutic role in this difficult condition. We are uncertain if the treatment contributed to the deterioration of the excised kidneys. This early experience suggests a need for careful consideration when contemplating this treatment, with attention directed to both the initial diagnosis and possibly the technique of capsaicin/instillation. We include a protocol to follow when preparing patients for capsaicin treatment.
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Affiliation(s)
- T Armstrong
- The Department of Urology, Royal Hospital Haslar, Gosport, Hampshire, UK
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Abstract
PURPOSE We review the long-term results of renal autotransplantation as a form of nephron sparing renal denervation for patients with the loin pain-hematuria syndrome. MATERIALS AND METHODS From 1985 to 1997, after exclusion of other urological, nephrological and psychiatric causes for severe intractable flank pain and recurrent hematuria, 22 patients with severe debility and heavy narcotic dependency underwent 26 renal autotransplantations for pain control. Postoperative pain relief, narcotic use, level of function in daily activities and status of the autograft were assessed. RESULTS Median and mean followup was 78.5 and 84.7 months (range 30 to 138), respectively. There were 2 technical failures. Pain recurred within 2 years after 6 procedures, of which 3 resulted in transplant nephrectomy and 3 were managed with a reduced analgesic requirement. Of the 16 patients with minimum 5 years of followup 12 (75%) were pain-free after surgery with 3 additional patients pain-free after transplant nephrectomy. Overall, 18 of the 26 autotransplant procedures (69.2%) resulted in pain relief, in some cases beyond 10 years, with patients returning to normal daily activities. CONCLUSIONS Renal autotransplantation results in durable narcotic-free favorable results in the majority of meticulously screened loin pain-hematuria syndrome patients. Although some failures, which usually occur within 2 years after surgery, can be expected, autotransplantation is justified as a nephron sparing denervation therapy for select loin pain-hematuria syndrome patients.
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Lall R, Mailis A, Rapoport A. Hematuria-loin pain syndrome: its existence as a discrete clinicopathological entity cannot be supported. Clin J Pain 1997; 13:171-7. [PMID: 9186025 DOI: 10.1097/00002508-199706000-00012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To (a) review existing literature and current concepts on Hematuria-Loin Pain Syndrome (HLPS) and (b) to describe seven cases of this syndrome. PATIENTS AND SETTING Seven HLPS patients seen over a period of 8 years by the pain and nephrology services of the Toronto Hospital, Toronto, Ontario, Canada. METHODS AND RESULTS Retrospective analysis was performed. All patients were remarkable for the variability of clinical presentation, pain characteristics, and dissociation of pain and hematuria occurrence. Routine renal investigations revealed different benign kidney pathologies in 5 of 7 patients. All patients, however, displayed variable combinations of personality factors, drug seeking behaviour, psychopathology, and presence of significant psychosocial stressors. Four cases were managed conservatively with antidepressants, anxiolytics, and supportive counseling and did very well despite persistent hematuria in two. CONCLUSIONS HLPS does not constitute a distinct clinicopathological entity. In a minority of cases only underlying kidney pathology is related to pain, and in many cases psychosocial stressors and underlying psychopathology may play a significant role in the reported disabling pain. A concerted medical/psychological approach is advocated.
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Affiliation(s)
- R Lall
- Pain Investigation Unit, Toronto Hospital, Ontario, Canada
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Autotransplantation as an Effective Therapy for the Loin Pain-Hematuria Syndrome. J Urol 1997. [DOI: 10.1097/00005392-199705000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Spitz A, Huffman JL, Mendez R. Autotransplantation as an Effective Therapy for the Loin Pain-Hematuria Syndrome: Case Reports and a Review of the Literature. J Urol 1997. [DOI: 10.1016/s0022-5347(01)64792-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Aaron Spitz
- From the Department of Urology, University of Southern California, Los Angeles, California
| | - Jeffry L. Huffman
- From the Department of Urology, University of Southern California, Los Angeles, California
| | - Robert Mendez
- From the Department of Urology, University of Southern California, Los Angeles, California
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ABSTRACTS FROM THE 48TH ANNUAL SCIENTIFIC MEETING OF THE UROLOGICAL SOCIETY OF AUSTRALASIA, HELD AT AUCKLAND HOSPITAL, AUCKLAND, NEW ZEALAND, 12–17 MARCH 1995. ANZ J Surg 1996. [DOI: 10.1111/j.1445-2197.1996.tb01215.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Disorders of glomerular structure and function are encountered frequently in clinical medicine. Many arise as part of a well-defined multisystem or multi-organ disease process, while in others the clinical and laboratory manifestations are consequent to the sole or predominant involvement of glomeruli. The latter are known as the primary glomerulopathies. These disorders can evoke a variety of clinical syndromes, including acute glomerulonephritis, rapidly progressive glomerulo-nephritis, nephrotic syndrome, "symptomless" hematuria and/or proteinuria, and chronic glomerulonephritis. The identification of underlying morphology, through the application of renal biopsy techniques, can provide useful information for both prognosis and treatment. Pathogenic mechanisms involved in the primary glomerulopathies are varied, but immunologic perturbations underlie many disease entities. This article describes the clinical features, pathology, natural history, and treatment of the main categories of primary glomerulonephritis, with emphasis on recent developments and practical aspects of diagnosis and management.
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Affiliation(s)
- R J Glassock
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, USA
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Abstract
Loin pain haematuria syndrome is a descriptive diagnosis of recurrent episodes of loin pain accompanied by haematuria, in which investigations do not reveal adequate pathology to account for the symptoms. The majority of patients present between 20 and 40 years, but onset may occur in older children. A significant number of patients show psychological and psychopathological features. Renal histology may show minor abnormalities, including mesangial proliferation, arteriolar and arterial hyalinosis and C3 in arterioles. Renal angiography is often normal but changes in intrarenal arterioles and cortical infarcts may be seen. Haematological abnormalities include decreased heparin-thrombin clotting time and elevated free plasma serotonin concentration. It is important that the assessment include a detailed psychiatric history, the patient's perception of pain, and the psychosocial environment. The pain may be very severe, leading to the requirement for addictive analgesics: management often becomes very difficult and frustrating to medical practitioners. Surgical intervention with capsulotomy, denervation and autotransplantation should only be considered as a last resort, as there is frequent recurrence of pain on the same or contralateral side.
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Affiliation(s)
- J R Burke
- Princess Alexandra, Royal Children's Hospital, Brisbane, Queensland, Australia
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